I, the undersigned commision to ZIPART Ltd. based in Poland 65-138 Zielona Gora Chynowska 8, performance oft he selected service of repair or diagnosis of the device (injection pump, driver, other) described below fort he price coherent with the price list presented on: www.vp44diesel.de.



1/1 Name and surname:


Address of return shipment

1/2 Street and number
1/3 Postcode
1/4 Town, country
1/5 Telephone number
1/6 Email:

Data for a VAT EU invoice (the same as in the revenue office) 1/6 Valid VAT EU number

1/7 Valid VAT EU number
1/8 The company's name:
1/9 The company's address:


(car’s data can be found in its car card)

2/1.No. Type Pump’s number Capacity Power Year Engine’s number:

or fill out:

2/2. Car’s mileage:

2/3. The cost of the service is in accordance with our price list and the repair will be done within 1-3 work days since the day of delivery.

2/4. The cost of return shipment by the GLS or UPS courier service will be added to the bill for the repair or diagnostic testing. Return shipment to Germany and Austria is free of charge.

Surcharge for return shipment to:

2/6. Payment conditions: a transfer to ZIPART’s bank account, Iban number: PL 95 1090 2532 0000 0001 0788 0433, BIC code (SWIFT): WBKPPLPP, with in 1-4 days from the day of the repair.

2/7. The prices given on our price list as first are net prices and they do not include VAT. In accordance with Polish tax regulations we can omit VAT (0% tax rate) if the repair is ordered by an employer from the EU who have a valid VAT EU number, within trade in the EU. If you are interested in net prices, it is necessary to write your VAT EU number in point 1/6 and fill out point 1/7 writing your company’s name and address the same as the one registered in the revenue office. T he condition to give you net prices (lower by 23% of VAT) is a positive verification of your company in the Central Office of Information Exchange by us.

2/8. The prices given on our price list as second are gross prices, they include 23% VAT and are directed to private persons and companies who do not have VAT EU number, and for private persons and companies from outside the EU.

2/9. Prices for clients from outside the EU are gross prices, they include 23% VAT, and they be higher by the amount of duty in accordance with current duty regulations.

2/10. Disputes connected with the contract the sides commit to settle amicably, and when the agreement cannot be found, all disputes will be settled in appropriate courts in Poland, which have exclusive jurisdiction with reference to any disputes connected with the contract.



3/1. Series number of the driver:

3/2. Date of production of the driver, below its serial number (day, month, year):

3/3. Has the defect been checked with the use of a diagnostic computer?:

3/4. Error code number showed by the diagnostic computer:

3/5. Description of the symptoms of the failure, i.e. is it possible to drive in limp-in mode or it is impossible to start the car?:


Date........................................ Employer’s signature: ........................................................